The Science
This is a study from Mecklenburg EMS and Carolinas Medical Center comparing the success rates of inserting a King LT-D airway by BLS providers and endotracheal intubation (ETI) by ALS providers with the outcome of first-time insertion success rates.

More than 350 patients were enrolled in the study—with approximately the same number of patients in each group. The results showed that BLS providers inserted a King airway successfully on the first attempt 87.8% of the time compared to ALS providers inserting an endotracheal (ET) tube 57.6% of the time. Investigators conclude that BLS insertion of the King LT-D is more successful the first time compared to ETI by ALS providers. However, they agree that more research is needed to assess this type of airway’s effects.

Medic Marshall: This is a small, straightforward study comparing airway management techniques. Although the impact of this study may be minimal, I believe it highlights some of the problems EMS organizations face when it comes to ETI: it’s a difficult skill to maintain. Mecklenburg EMS is a high-quality service with almost 100,000 calls per year and more than 70,000 transports per year. It has more than 400 paramedics, EMTs, and emergency medical dispatchers. Do you really think all of those paramedics perform enough intubations annually to maintain competency? I doubt it—especially given the numbers in this study.

One I thing I hear so often is, “Well, if we just had more training and education on it,” or “Can’t we just get into the hospitals’ operating room (OR) for a day?” I think those two options would definitely help us out, and ETI probably wouldn’t be an issue. Unfortunately, those two things are costly on top of the fact that EMS providers have to compete with residents, nurse anesthetists and other students for the chance to tube patients. It’s just not feasible.

At the end of the day, I’m not against paramedics intubating in the field. In fact, I think it’s a very valuable skill. But the future of EMS and healthcare lies in evidence-based medicine. And I really don’t find any evidence for a cost-effective means to continue the practice of ETI in the field.

Doc Wesley: I have to agree with Marshall on the overall conclusion of this study. There is no question that blind airway devices are easier and quicker to insert and that both BLS and ALS providers can be equally proficient in their use with minimal training.

However, some conditions exist that absolutely do better with an ET tube. So the question is how do we, as a system, ensure that availability of this potentially lifesaving skill? I agree that sending every medic to the OR and having mandatory mannikin intubations doesn’t equate to intubation proficiency. The AHA states that proficiency requires 6–12 intubations a year.

One solution may be to limit the number of intubation-qualified medics as clinical supervisors who can be sent to the scene of intercept with the crew needing their skill. Another idea is for us to examine the supraglottic airway devices that permit intubation of the trachea through them.

There is no question that this controversy will continue to burn, but we must be willing to face the facts that science is providing us and prepare to make some hard decisions.

AbstractObjective: The objective of this study was to compare the frequency of first attempt success between basic life support (BLS) first responder initiated King LT-D placement and paramedic initiated endotracheal intubation (ETI) among patients experiencing out-of-hospital cardiac arrest (OOHCA).

Methods: In 2009 a large, urban EMS agency modified their out-of-hospital, non-traumatic, cardiac arrest protocol from paramedic initiated ETI to first responder initiated King LT-D placement. This retrospective analysis of all adult, non-traumatic cardiac arrests occurred four months before and four months after protocol implementation. The outcome variable in this analysis was first attempt airway management success defined as placement of the device with end tidal CO2 wave form or colorimetric color change, auscultation of bilateral breath sounds, and improved or normal pulse oximetry reading. The independent variable of interest was initial device utilized to secure the airway, King LT-D or ETI.

Results: There were 351 adult, non-traumatic OOHCAs with 184 patients (52.4%) enrolled during the ETI period and 167 (47.6%) during the King LT-D period. The frequency of first attempt success was 57.6% in the ETI group and 87.8% in the King LT-D group. Patients in the King LT-D group were significantly more likely to experience first attempt success versus standard ETI methods (OR 5.3; 95%CI 2.9–9.5).

Conclusion: In this analysis of OOHCA airway management, first attempt BLS King LT-D placement success exceeded that of first attempt paramedic ETI success. In addition, patients in the King LT-D group were more likely to have had an advanced airway attempted and to have had a successful advanced airway placed when multiple attempts were required.